We place the patient in the dorsal lithotomy position using standard operative stirrups. With the table flat, we then tuck the patient’s arms at the side. All pressure points are protected using standard eggcrate foam padding. Sequential compression stocking devices are placed on both legs and are activated. We also routinely administer 5000 units of subcutaneous heparin. Next, the patient is secured to the operating table using a cross-shoulder harness made by four strips of eggcrate foam padding. Each strip is 6 × 24 in., and two strips are used on each side of the patient creating an “X” configuration across the patient’s chest. The pads are secured to the operating table using cloth tape. Care must be taken not to secure the lower portion of the pads below the costal margin, as this may interfere with subsequent lateral trocar placement. Once the patient is secured to the table, the leg attachment is lowered and the patient is placed in 30–40° steep Trendelenburg position (Fig. 16.2). Of note, the anesthesia team places an orogastric tube to low wall suction for the duration of the case, and a foam padding is placed over the patient’s face to prevent injury from the camera, particularly when the 30°-down lens is being used. A urethral catheter is placed on the operative field.

Our standard trocar configuration for robot-assisted radical cystectomy is shown in Fig. 16.3. Insufflation of the abdominal cavity is performed using a Veress needle to 15 mmHg, which in general is maintained throughout the operation. In particularly obese patients, communication with the anesthesia team is imperative as pneumoperitoneum can result in unacceptably high inspiratory pressure necessitating a lower abdominal insufflation pressure. Once the abdomen has been insufflated, we place a 10–12 mm, blunt, disposable trocar in the periumbilical location as our camera trocar. We mark a standard laparotomy incision at the beginning of the case and use the superior 1 cm of the curvilinear, periumbilical portion of the incision for our robotic camera trocar. The 30°-up lens is then passed through this trocar to aid in subsequent trocar placement. At this point, the left 8 mm robotic trocar is placed 10 cm lateral to, and 2 cm inferior to, the camera trocar. A second 8 mm robotic trocar is placed in the midaxillary line 3 cm superior to the ASIS . With the assistant on the left holding the camera, we then place our right 8 mm robotic trocar 10 cm lateral to, and 2 cm inferior to, the camera trocar. A Versaport™ Plus (Covidien, Mansfield, MA), 5–15 mm trocar, is then placed as the main right assistant trocar in the midaxillary line 3 cm superior to the anterior superior iliac spine (ASIS ). A 5 mm AirSeal^® Access Port (SurgiQuest, Milford CT) used primarily by the right-sided assistant for suction-irrigation is then placed midway between the camera trocar and the right robotic trocar. We place our suction trocar in the same axial plane as the camera trocar, because placement of this trocar in a lower position can limit movement between the camera and right robotic arm. Because our suction is in a slightly higher position, we use the extra long suction tip adapter to reach the most dependent portions of the pelvis.